RE: Advancing Interoperability and Health Information Exchange

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1 April 21, 2013 Ms. Marilyn Tavenner Acting Administrator, Chief Operating Officer Centers for Medicare and Medicaid Services Department of Health and Human Services 7500 Security Boulevard Baltimore, MD RE: Advancing Interoperability and Health Information Exchange Dear Acting Administrator Tavenner: As a part of the physician community, the American Academy of Physical Medicine and Rehabilitation (AAPM&R) appreciates the opportunity to address the questions posed in the agency s request for information dated March regarding Health Information Exchanges (HIEs). The AAPM&R is the national medical society representing more than 8,000 physiatrists, physicians who are specialists in the field of physical medicine and rehabilitation (physiatry). Physiatrists treat adults and children with acute and chronic pain, persons who have experienced catastrophic events resulting in paraplegia, quadriplegia, traumatic brain injury, spinal cord injury, limb amputations, rheumatologic conditions, musculoskeletal injuries, and individuals with neurologic disorders or any other disease process that results in impairment and/or disability. With appropriate rehabilitation, many patients can regain significant function, and live independent, fulfilling lives. The AAPM&R firmly believes that it is important that all settings of care collect like data in order to increase the quality and coordination of healthcare across settings and diagnostic categories. In addition to answering the questions posed by CMS, AAPM&R would also like to advocate that, in order to effectively implement Health Information Exchanges (HIE) and increase adoption in post acute care providers, the following barriers must be addressed: Post acute care facilities and providers should be incentivized, much like acute care providers, to implement expensive Electronic Health Record (EHR) systems. To address this issue, the Academy would advocate for extending meaningful use and setting up benchmarks exclusively for post acute care providers to help ease the transition. Currently, there is a lack of EHR solutions that address the needs of post acute care providers. Specifically, many providers in the post acute setting will need to utilize functional assessment tools, such as the Functional Independence

2 Measure (FIM), and have access to interdisciplinary documentation with the ability for multiple authors to contribute. There is a critical need for Office of the National Coordinator for Health Information Technology (ONC) certification to require EHR functionality to meet any regulatory mandates for care, such as, documentation standards requirements for Inpatient Rehabilitation Facilities (IRFs), specifically preadmission screening, post admission evaluation, and individualized overall plans of care. In order for a successful nationwide ability to exchange data, there must first be HIEs created at a state and local level that can receive information from any provider. Likewise providers must be able to access information easily from these HIEs. Currently, many HIEs have been created piecemeal, making a national infrastructure problematic. It is important to implement data standards for HIEs that venders must employ in order to allow easy communication between their EHR product and the HIEs. In certain instances it may be untenable to create HIEs solely at the state level. For example, metropolitan areas that span multiple states could have barriers to linking state-based HIEs, thus diminishing the value. National standards should be put into place to address this issue. Furthermore the interface needed to communicate with the HIE must be part of the initial installation for any EHR software. It is vital to focus on usability for providers and hospitals. Many providers point to barriers in usability and functionality of current EHR solutions as to the reason that they are not embraced. Poor usability by many electronic health records creates risk for more errors as well as inefficient delivery of healthcare. On potential solution would be to make usability part of ONC certification. QUESTIONS FOR PUBLIC COMMENT Question #1: What changes in payment policy would have the most impact on the electronic exchange of health information, particularly among those organizations that are market competitors? The Academy believes that if HIEs were utilized to tie reimbursement to the electronic submission of data, adoption would increase. Question #2: Which of the following programs are having the greatest impact on encouraging electronic health information exchange: hospital readmission payment adjustments, value-based purchasing, bundled payments, ACOs, Medicare Advantage, Medicare and Medicaid EHR incentive programs (meaningful use), or medical/health homes? Are there any aspects of the design or implementation of these programs that are limiting their potential impact on encouraging care coordination and quality improvement across settings of care and among organizations that are market competitors?

3 Because it is critical to have incentives to help defray the cost of EHR implementation, the Academy believes that the meaningful use incentive program could serve as a base for HIE participation incentives and penalties for post acute care. Once initial systems are in place, later stages of meaningful use could include measures for HIE participation. Also, as part of Accountable Care Organization (ACO) certification, CMS could provide incentives for the standardized use of EHR and HIE integration, and even include EHR use as part of value based purchasing by raising providers utilizing EHRs to a higher tier. Question #3: To what extent do current CMS payment policies encourage or impede electronic health information exchange across health care provider organizations, particularly those that may be market competitors? Furthermore, what CMS and ONC programs and policies would specifically address the cultural and economic disincentives for HIE that result in data lock-in or restricting consumer or provider choice in services or providers? Are there specific ways in which providers and vendors could be encouraged to send, receive, and integrate health information from other treating providers outside of their practice or system? The AAPM&R believes that by developing the personal health record (PHR) as part of the HIE and having vendors compete at the state level to create PHRs that easily interface with EHRs is key for advancement. Also, barriers for interoperability, including the need for providers and systems to invest significant money in creating interfaces that allow interoperability must be addressed. One way could be to incentivize venders to create standardized interfaces and include these as part of the base software purchase in order to facilitate easy flow of information. Question #4: What CMS and ONC policies and programs would most impact post acute, long term care providers and behavioral health providers exchange of health information, including electronic HIE, with other treating providers? How should this programs and policies be developed and/or implemented to maximize the impact on care coordination and quality improvement? The Academy believes that post acute care facilities and providers should receive incentives, much like acute care providers do as part of meaningful use. It is also important to incentivize allied health professionals including, physical therapists, occupational therapists, and speech language pathologists, who belong to independent practices. There is also a need to develop meaningful use standards that apply specifically to post acute care, such as the ability to meet regulatory documentation compliance for IRFs and Skilled Nursing Facilities (SNFs). Finally, it is critical to focus on developing standards for HIEs so that all providers and facilities are able to easily send or receive data from an HIE. It is also important that HIEs have the ability to communicate with one another.

4 Question #5: How could CMS and states use existing authorities to better support electronic and interoperable HIE among Medicare and Medicaid providers, including post acute, long term care, and behavioral health providers? The AAPM&R would advocate for states to implement statewide or regional HIEs. Once established, the information exchange between state or regional HIEs should be the next step in the process. Question #6: How can CMS leverage regulatory requirements for acceptable quality in the operation of healthcare entities, such as conditions of participation for hospitals or requirements for SNFs, NFs, or home health to support and accelerate electronic, interoperable health information exchange? How could requirement for acceptable quality that involve health information exchange be phased in overtime? How might compliance with any such regulatory requirements be best assessed and enforced, especially since specialized HIT knowledge may be required to make such assessments? The Academy feels strongly that, in the early stages of HIE adoption, meeting acceptable quality as regulated should not be included as a condition of participation. Rather, it should be phased in overtime as adoption increases. Question #9: What CMS and ONC policies or programs would most impact patient access and use of their electronic health information in the management of their care and health? How should CMS and ONC develop, refine and/or implement policies and programs to maximize beneficiary access to their health information and engagement in their care? The AAPM&R believes that patients need to have a stake in the implementation of EHRs and increased involvement in their healthcare. Finding a way to incentivize patients to sign up for portals, communicate electronically, and promote their own wellness is important for engagement. However, it is not appropriate to penalize providers for low levels of patient participation.

5 The American Academy of Physical Medicine and Rehabilitation thanks the Agency for the opportunity to share its thoughts on the questions posed regarding implementation of health information exchanges. We remain committed to being part of the solution to encourage free flow of health information in a coordinated fashion and we hope these comments provide meaningful perspective in your deliberations over implementation. If you have any questions or require more information, please contact Sarah D Orsie, Manager of Government Affairs, at or (202) Sincerely, Douglas A. Wayne, MD Chair Practice Resources Committee (PRC) American Academy of Physical Medicine & Rehabilitation (AAPM&R)

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